Medicare Payment Updates for RHCs

Telehealth (G2025) Coinsurance and Reimbursement Policy Updated


The MLN Matters SE20016 was recently updated in a way that significantly alters G2025 reimbursement policy. The updated section is as follows:

Telehealth Services with Cost-Sharing

For the CPT and HCPCS codes included in the list of telehealth codes at the link above, we’ll adjust the coinsurance and payment calculation for distant site telehealth services you furnished to reflect the method used to calculate coinsurance and payment under the PFS. The coinsurance for these services will be 20% of the lesser of the allowed amount ($92.03) or actual charges, and the payment will be 80% of the lesser of the allowed amount ($92.03) or the 
actual charges.

Before the adjustment, the coinsurance for distant site services you furnished was 20% of the actual charges and the payment was the allowed amount ($92.03) minus the coinsurance.

MACs will automatically reprocess any claims with HCPCS code G2025 for services furnished on or after January 27, 2020 through November 16, 2020 that were paid before we updated the claims processing system to pay HCPCS code G2025 based on the “lesser of” methodology, as described above.

The above language is the exact language from CMS. Unless your G2025 charges were always exactly $92.03, adjustments are coming. We have also inquired with CMS as to when they will be announcing the updated G2025 rate for 2021 and will be sure to post when we have that confirmed.

The NARHC is currently advocating for a permanent extension of the telehealth policy wherein RHCs receive their All-Inclusive Rate and not this “composite rate” policy established for Public Health Emergency.

2021 RHC Upper Limit Updated to $87.52

The RHC upper limit, more commonly known as the RHC cap has been updated to $87.52 for 2021.

As most of you know, the RHC upper limit applies to all independent RHCs as well as RHCs owned by hospitals with 50 or more beds. CMS updates the upper limit each year based on something called the "Medicare Economic Index" or MEI per the Medicare statute.

NARHC is advocating for modernization of the statute as we believe the current policy and reimbursement cap is woefully outdated.